Psychiatry at the Margins crossed 5,000 total subscribers a few days ago! It’s hard to believe at times, but also very heartening, that so many across the globe are interested in what this publication has to offer. This newsletter is little more than a year old at present. If you are among the new readers, I am an early-career psychiatrist in the US with an interest in critical and philosophical issues in the field. The About page has a list of posts that you can use to explore past content.
The debate over how to make sense of STAR*D cumulative remission data continues. The latest development is one I was not anticipating at all. A paper in World Psychiatry by Sakurai et al. tries to account for missing data in STAR*D with a new statistical analysis. They estimate the cumulative remission rate by using the inverse probability of censoring weighted (IPCW) Kaplan-Meier method. Furthermore, they compare cumulative remission rates among individuals with and without prior antidepressant treatment history during the ongoing episode. Their analysis is based on QIDS-SR16, and takes the burden of side effects into account, as well as a variety of other factors, such as the baseline depression score. They estimate the cumulative remission rate to be 53.8% at 90 days, 74.5% at 180 days, and 87.5% at 360 days! Cumulative remission for those who had received no antidepressant prior to study entry for the current episode is even higher at 89.1%.
STAR*D authors had estimated a cumulative remission rate of 67% by assuming that those who exited the study would have had the same remission rates as those who stayed in the protocol. Pigott et al. treated all dropouts as non-remitters and calculated a rate of 35%. The Sakurai et al. analysis suggests that the remission rate of drop-outs may actually be higher than that of those who stayed in the study! A somewhat counterintuitive finding, but not without precedent. My suspicion is that the method used by Sakurai et al. overestimates the cumulative remission rate, but their analysis does seem to converge with findings from other studies, such as NESDA which reported a depression remission rate of 79.5% over a two-year period and a median time to remission of 6 months. Pigott et al.’s analysis is definitely more faithful to the spirit of the protocol, but it seems unlikely to be the best interpretation of what the STAR*D data shows.
Scott Alexander has written two posts on
on the genetics of schizophrenia, in response to Torrey’s article and my recent posts. If you’ve been following the discussion, I highly recommend reading them: Some Unintuitive Properties Of Polygenic Disorders and It's Fair To Describe Schizophrenia As Probably Mostly Genetic. (Here’s my comment on his second post)It’s time to admit that genes are not the blueprint for life — Philip Ball’s latest book, How Life Works, challenging the conventional, gene-centric view of biology, gets a favorable review in Nature: “the genome turned out to be no blueprint. In fact, most genes don’t have a pre-set function that can be determined from their DNA sequence.”
Ellen Barry in the New York Times, The Man in Room 117. The story of Andrey Shevelyov illustrates really well the challenges that accompany chronic psychosis and impaired insight, and how both patients and families struggle to find meaningful and lasting solutions in the US mental healthcare system.
The concept of “representation” in neuroscience is receiving a lot of scrutiny. A study conducted by Favela and Machery showed that neuroscientists are uncertain about how to apply the concept of representation (in contrast to causal and information-theoretic concepts) — see summary of their findings on the Brains Blog. On the Transmitter, Representation: Past, Present and Future (RPPF) project has started a series of essays aimed at clarifying the fuzzy concept of representation in neuroscience and beyond, see first essay here.
The New York Review — James Gleick has written a wonderful summary and review of Kevin Mitchell's book Free Agents; in the book Mitchell offers a detailed scientific and philosophical defense of agency and free will.
A fascinating debate recently happened in the pages of the American Journal of Psychiatry with regards to the psychotherapy component of “psilocybin assisted psychotherapy.” Goodwin et al. wrote a provocative article, “Must Psilocybin Always “Assist Psychotherapy”?” which generated a flurry of letters, and the authors defended their position in response. Goodwin et al. weren’t arguing for eliminating all forms of psychological support that accompany psilocybin administration, nor were they saying that such psychological support is useless; their central argument seems to be that the psychological support component helps patients get the optimal therapeutic benefit from psilocybin administration, and “it is hard for us to see psilocybin as “assisting psychotherapy” when it is clearly the other way around.”
From my Substack friends:
writes about a Unified Field Theory of Human Flourishing, shares an excellent list of recommendations to learn more about philosophy of science, and writes about the controversial link between violence and schizophrenia.The March 2023 issue of Philosophy, Psychiatry, & Psychology is currently open-access. This issue celebrated the 30th anniversary of the journal with a series of editorials on the past, present, and future of the journal and the philosophy of psychiatry community. Read my editorial here, and see this past Substack post for an overview of the editorials.